Improving Delirium Recognition in Trauma and Orthopaedic Elderly care Through Simulation

Background:

Delirium is a frequent and serious complication in older trauma patients, affecting an estimated 20–60%, particularly after fractures, spinal injuries, and prolonged immobilization. It typically arises from a combination of factors, including the acute effects of injury, pain, polypharmacy, infection, constipation, urinary retention, and physiological stress layered onto existing comorbidities and reduced cognitive reserve. Despite its impact, delirium is often under-recognised in busy ward settings, where hypoactive presentations are easily mistaken for fatigue, low mood, or baseline cognitive decline. Delayed recognition can lead to adverse outcomes including falls, aspiration pneumonia, prolonged hospital stays, and increased mortality. Although up to one-third of cases are preventable, gaps persist in frontline staff recognition of early signs, precipitating factors, and effective non-pharmacological management. Traditional didactic teaching has limited impact on clinical practice, whereas simulation-based education offers an experiential approach to improve recognition of subtle behavioural changes and safety-focused decision-making. 
 
What was tried:

In our study, four sets of high-fidelity simulation sessions were conducted for nurses and healthcare assistants (HCAs) based on trauma and orthopaedic wards during 2024-2025. A total of 27 nurses and 8 HCAs participated. Two simulation scenarios focused on hyperactive delirium in a trauma patient with constipation and a spinal fracture, while another scenario addressed hypoactive delirium associated with urinary retention. The simulations aimed to assess delirium identification, use of non-clinical interventions to reduce confusion, maintenance of patient safety, and appropriate escalation of care. Neck collar care was incorporated and observed during scenarios, followed by multidisciplinary debriefs including therapy input. Recent simulations also introduced Speech and Language Therapy (SALT)–focused discussions to reinforce the importance of early swallow assessment in trauma patients. 

Outcomes:

Delirium simulation represents an effective educational innovation for improving staff understanding, recognition, and management of delirium in elderly trauma patients, ultimately contributing to improved patient safety and outcomes. Post-simulation feedback and observational data using 4AT scoring demonstrated a significant improvement in delirium recognition, particularly in trauma patients. We further reviewed that over the preceding year, there were no deaths related to aspiration pneumonia and improving LOS from 11 to 8 days.